Cross-enterprise workflow

ABSTRACT

Example systems, methods and storage media to provide a cross-enterprise workflow among clinical systems are disclosed. An example cross-enterprise enabled clinical information system includes a workflow manager to coordinate user workflows with respect to the system and associated content. The system includes an image services manager configured to manage images and associated services for the system and associated content. The workflow manager and image services manager are configured for cross-enterprise content sharing such that the system is to locally authenticate a user at the system and the system is to locally authorize a remote request for access to content at the system from a remote user that has been authenticated remotely. The system is arranged to provide content in response to the remote request after the remote authentication has been received and the system has verified the remote user&#39;s authorization for access.

RELATED APPLICATIONS

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FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT

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MICROFICHE/COPYRIGHT REFERENCE

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BACKGROUND

Healthcare practitioners may review medical exam results stored ininformation systems such as hospital information systems (HIS),radiology information systems (RIS), clinical information systems (CIS),cardiovascular information systems (CVIS, etc., and storage systems suchas picture archiving and communication systems (PACS), libraryinformation systems (LIS), and electronic medical records (EMR).Information stored can include patient medication orders, medicalhistories, imaging data, test results, diagnosis information, managementinformation, and/or scheduling information, for example. The healthcarepractitioners may obtain the information from information systemsincluded in the healthcare environment, such as hospitals or clinics, inwhich the practitioner practices (e.g., local information systems) orfrom information systems included in other healthcare environment(s)(e.g., foreign or remote information system(s)).

BRIEF SUMMARY

Example systems, methods and tangible computer readable storage media toprovide a cross-enterprise workflow among clinical systems are disclosedand described.

Certain examples provide a cross-enterprise enabled clinical informationsystem. The example system includes a workflow manager to coordinateuser workflows with respect to the system and associated content. Theexample system also includes an image services manager configured tomanage images and associated services for the system and associatedcontent. The example workflow manager and image services manager areconfigured for cross-enterprise content sharing such that the system isto locally authenticate a user at the system and the system is tolocally authorize a remote request for access to content at the systemfrom a remote user that has been authenticated remotely. The examplesystem is arranged to provide content in response to the remote requestafter the remote authentication has been received and the system hasverified the remote user's authorization for access. At least one of theworkflow manager and the image services manager is to provide content tothe remote user depending upon a type of requested content.

Certain examples provide a tangible computer readable storage mediumincluding instructions which, when executed, implement across-enterprise enabled clinical information system. The example systemincludes a workflow manager to coordinate user workflows with respect tothe system and associated content. The example system also includes animage services manager configured to manage images and associatedservices for the system and associated content. The example workflowmanager and image services manager are configured for cross-enterprisecontent sharing such that the system is to locally authenticate a userat the system and the system is to locally authorize a remote requestfor access to content at the system from a remote user that has beenauthenticated remotely. The example system is arranged to providecontent in response to the remote request after the remoteauthentication has been received and the system has verified the remoteuser's authorization for access. At least one of the workflow managerand the image services manager is to provide content to the remote userdepending upon a type of requested content.

BRIEF DESCRIPTION OF SEVERAL VIEWS OF THE DRAWINGS

FIG. 1 illustrates example RIS and PACS providing order lifecyclemanagement (via the RIS) and image lifecycle management (via the PACS).

FIG. 2 illustrates an example relationship between a RIS and a PACS.

FIG. 3 shows a high level view of an example integrated system includinga workflow manager and an image service manager.

FIG. 4 illustrates an example backend for an integrated clinicalinformation system.

FIG. 5 illustrates an example integrated clinical information system.

FIG. 6 depicts an architecture diagram for an example integratedclinical system.

FIGS. 7-19 illustrate a plurality of example configurations forcross-enterprise communication and collaboration with an integratedclinical system.

FIG. 20 illustrates an example cross-enterprise data flow diagramshowing examples of local data access versions cross-enterprise dataaccess.

FIG. 21 shows an example of vendor neutral viewer via a decentralizedmodel with a local data access deployment model.

FIG. 22 illustrates an example vendor neutral viewer of global priorsfor a patient.

FIG. 23 illustrates an example vendor neutral viewer of a study file.

FIG. 24 illustrates an example vendor neutral viewer of image access.

FIG. 25 is a flow diagram representative of example computer/machinereadable instructions that may be executed to implement the examplesystems and configurations disclosed and described with respect to FIGS.1-24.

FIG. 26 is a block diagram of an example processing platform capable ofexecuting the example computer/machine readable instructions and/or toimplement the example systems of FIGS. 1-25.

The foregoing summary, as well as the following detailed description ofcertain examples of the present invention, will be better understoodwhen read in conjunction with the appended drawings. For the purpose ofillustrating the invention, certain examples are shown in the drawings.It should be understood, however, that the present invention is notlimited to the arrangements and instrumentality shown in the attacheddrawings.

DETAILED DESCRIPTION OF CERTAIN EMBODIMENTS

Although the following discloses example methods, systems and computerreadable media including, among other components, software and/orfirmware executed on hardware, it should be noted that such methods andapparatus are merely illustrative and should not be considered aslimiting. For example, it is contemplated that any or all of thesehardware, software, and firmware components could be embodiedexclusively in hardware, exclusively in software, or in any combinationof hardware and software. Accordingly, while the following describesexample methods, systems, and computer readable media, persons ofordinary skill in the art will readily appreciate that the examplesprovided are not the only way to implement such methods, systems andcomputer readable media.

The present disclosure relates generally to healthcare applications,and, more particularly, to methods, systems, and apparatus to provideintegrated workflow and image services via standalone and/orcross-enterprise system configurations.

Many healthcare environments include radiology information systems tofacilitate patient examination and/or patient diagnosis. For example, aradiology information system in a healthcare system can store radiologyreports, messages, warning, alerts, patient scheduling information,patient demographic data, patient tracking information, and/or physicianand patient status monitors.

Typically, a medical exam ordered for a patient is assigned to apractitioner (e.g., a radiologist) to conduct the exam. A medical examconducted on a patient can involve review by a healthcare practitioner(e.g., a radiologist) to obtain, for example, diagnostic informationfrom the exam. In a hospital setting, medical exams can be ordered for aplurality of patients, all of which involve review by an examiningpractitioner. Each exam may have associated attributes, such as amodality, a part of the human body under exam, and/or an exam prioritylevel related to a patient criticality level. In some examples, however,not all the information needed for reviewing a medical exam is locallyavailable. For example, a practitioner (e.g., a radiologist or atechnician) may want to review information about a patient, but theinformation may be spread across different information systems.

In some systems, the practitioner may review printouts of theinformation from the different information systems. However, theprintouts may not include up-to-date information. For example,information in an information system may be updated to include a newresting heart rate for the patient. In some systems, the practitionermay access the information from the different information systems bymanually connecting to each of the necessary information systems. Thiscumbersome process of logging into an information system wheneverinformation from that information system is needed can cause thepractitioner to obtain the information less frequently. Thus, thepractitioner may review the medical exam (or record) for the patientwith stale information.

In some systems, a healthcare institution builds a unified system thatincludes all the data from the different information systems. Forexample, the unified system can populate the unified system with all theinformation stored in a first hospital information system, a secondhospital information system, a radiology information system, etc. Suchunified systems necessitate large databases to store all of theinformation. Further, transforming the information (e.g., cleansing,reformatting, standardizing, aggregating and/or applying any number ofbusiness rules) from the different information systems into a singleformat as needed for the unified system can be impractical. For example,each of the different information systems may be controlled by differentbusiness rules or service level agreements, store the information indifferent formats, include different definitions for optional elementsversus required elements, etc. In addition, if the information istransformed at the unified system, returning the data (e.g., informationupdated by the practitioner) to the source information system can beunreasonable.

Disclosed and described herein are example systems, methods and computerreadable media that provide for integration between a radiologyinformation system (RIS) and a picture archiving and communicationsystem (PACS) according to a single data schema. A schema is a structuredescribed according to a language and/or other format to provide one ormore formula, format, integrity constraint, relationship, attribute,rule, etc., to organize, relate, process, and/or store information.

Using single schema-based integration, certain examples facilitateoperation with a plurality of workflow back-ends. Unlike other solutionswhich require integration between disparate systems/sub-systems, certainexamples abstract and extract domain specific entities into updatabledatabase views. A new application is then constructed on top of thisschema. The new application is agnostic to the underlying databasestructure (that belongs to one or more existing products).

Certain examples provide a “bolt-on approach” allowing for immediate useof existing data by the new application without synchronization. Certainexamples use Extract, Transform, Load (ETL) to extract data from outsidesources, transform the extracted data to fit operational needs, and loadthe transformed data into an end target data store. Certain examplesreduce install/upgrade time and service costs by reducing or eliminatingETL in accordance with the single schema. Certain examples facilitatethese operations via the new application while the existing baseapplication continues to function as before, oblivious to another (e.g.,competing) application (e.g., the “new” application) working on the sameschema/dataset. This allows customers to slowly transition from anexisting application to the new and different application while notsuffering from data migration to do so.

In certain examples, a hospital information system (HIS) stores medicalinformation such as clinical reports, patient information, and/oradministrative information received from, for example, personnel at ahospital, clinic, and/or a physician's office. A RIS stores informationsuch as, for example, radiology reports, radiology exam image data,messages, warnings, alerts, patient scheduling information, patientdemographic data, patient tracking information, and/or physician andpatient status monitors. Additionally, the RIS enables exam order entry(e.g., ordering an x-ray of a patient) and image and film tracking(e.g., tracking identities of one or more people that have checked out afilm). In some examples, information in the RIS 106 is formattedaccording to the HL-7 (Health Level Seven) clinical communicationprotocol. In certain examples, a medical exam distributor is located inthe RIS to facilitate distribution of radiology exams to a radiologistworkload for review. In an alternative example, the exam distributor canbe located separately or can be included in any other suitable device ofthe healthcare system.

A PACS stores medical images (e.g., x-rays, scans, three-dimensionalrenderings, etc.) as, for example, digital images in a database orregistry. In some examples, the medical images are stored in the PACSusing the Digital Imaging and Communications in Medicine (“DICOM”)format. Images are stored in the PACS by healthcare practitioners (e.g.,imaging technicians, physicians, radiologists) after a medical imagingof a patient and/or are automatically transmitted from medical imagingdevices to the PACS for storage. In some examples, the PACS can alsoinclude a display device and/or viewing workstation to enable ahealthcare practitioner or provider to communicate with the PACS.

Diagnostic and medical image processing solutions such as PACS and RIShelp to drive and support digital images and patient data throughimproved image storage, viewing, sharing and retrieval, resulting in animprovement in workflow efficiency and productivity. Such improvementsare of growing importance as the world population ages andco-morbidities increase demand for medical imaging and analytics and aresulting need for image processing and management for large volumes ofdata.

Additionally, PACS have evolved from a tool for medical image viewing,distribution, and archiving into a system supporting clinical decisionmaking. PACS can include advanced visualization tools, voice recognitionsolutions, customized worklists, teleradiology, cloud-based PACS,zero-footprint viewers, and mobile PACS, for example. PACS may beintegrated with three-dimensional (3D) 3D visualization, maximumintensity projection (MIP), and multi-planar reformation (MPR) tools,for example.

In certain examples, Vendor-Neutral Archiving (VNA) can be used in placeof and/or in addition to a PACS for image archiving and/or otherstorage. Using a VNA, a plurality of different PACS and/or otherdifferent systems can store and retrieve images without translation ortransformation at the VNA. An enterprise archive (EA) can also be usedwithin an enterprise to storage and later retrieve image and/or otherdata, for example.

RIS/PACS Relationships

Turning now to the figures, FIG. 1 illustrates example RIS 102 and PACS120 providing order lifecycle management (via the RIS 102) and imagelifecycle management (via the PACS 120). As depicted in the example ofFIG. 1, the RIS 102 is an order lifecycle management system. That is,the RIS 102 is an order filler. The RIS 102 works in an order domainwhere an order is a center of focus and activity. As depicted in theexample of FIG. 1, the PACS 120 is an image lifecycle management system.The PACS 120 works in a study domain where an image is a center of focusand activity.

The order and image domains do not overlap and do not compete in aworkflow. Rather, the domains are complementary and in lock step. Alarger departmental workflow encompasses both the RIS 102 and the PACS120.

As shown in the example of FIG. 1, the RIS 102 documents a patient 104who has one or more visits 106 that may include one or more exams 108.One or more actions 110-118 can be executed and documented with respectto the exam 108. For example, the exam can be billed 110, distributed111, reported 112, read 113, ordered 114, scheduled 115, patient arrival116, started 117, completed 118, etc.

As shown in the example of FIG. 1, the PACS 120 documents a study 122including one or more series 124 of one or more images 126. Each image126 can be acquired 130, archived 131, made available online 132,deleted 113, etc., via the PACS 120, for example.

FIG. 2 illustrates an example relationship between a RIS and a PACS. Asillustrated in the example of FIG. 2, a radiologist reads an exam byretrieving exam information 206 from a visit 204 for a patient 202 fromthe RIS and information on an image 212 from a series 210 in a study 208from the PACS. A report is generated by the radiologist and stored inthe RIS. Additionally, a technologist can edit one or more studies 208in the PACS as well as one or more exams 206 in the RIS. Exceptionhandling can be provided in both the RIS and the PACS, for example. Aradiology administrator can also edit or more studies 208, exams 206,etc.

By combining and/or otherwise tightening a relationship between the RISand the PACS, a usability experience can be improved for a radiologist,technologist, radiology administrator, and so on. Certain examplesprovide a single (e.g., seamless or substantially seamless) userinterface that allows users to perform their work regardless of whetherthe work impacts the RIS and/or PACS. In certain examples, an orderlifecycle manager can be provided with an image viewer, while imagelifecycle management (traditionally handled by the PACS) is left to anEA.

The order domain model and the image domain model are related by asingle relationship between the exam 206 (e.g., accession number) andthe study 208 (e.g., study instance unique identification number (UID)).Further, exam 206 and study 208 are related by an M:N relationship. Oneexam 206 can be associated with more than one study 208 and vice versa.A practical relationship is between an exam 206 and one or more series210.

Example RIS/PACS Integration

FIG. 3 shows a high level view of an example integrated system 300including a workflow manager 310 and an image service manager 320. Asillustrated in the high-level system view 300, traditional RIS and PACSfunctionality can be replaced by the workflow manager 310 workingtogether with the image service manager 320. Images and associatedservices can be managed by the image service manager 320 while theworkflow manager 310 coordinates user workflows (e.g., radiologistworkflow, technologist workflows, administrator workflows, etc.).

FIG. 4 illustrates an example backend 400 for an integrated clinicalinformation system. The example system 400 includes a RIS 410 and an EA420. As illustrated in the example of FIG. 4, while functionalitycrosses domains (e.g., study file/smarting hanging protocol (SHP) 431(SHP may also be referred to as a smarting reading protocol, forexample), exception management/matching/profiling 432,collaboration/multidisciplinary team (MDT) 433, prefetch 434, etc.),services do not cross domains (e.g., order management 412, worklist 413,reporting 414, billing 415, messaging (e.g., HL7) 416, support 417,cross-enterprise document sharing (XDS) 421, modality performedprocedure step (MPPS) 422, Digital Imaging and Communications inMedicine (DICOM) services 423, etc.). Thus, while functionality maystill have separate modules and components are oblivious to each otherin the architecture, they can function together in the same system.

The RIS 410 can also include a combination of service-orientedarchitecture (SOA), business process management (BPN), and an enterpriseservice bus (ESB) 411, for example. Web services can be used provideisolation and/or separation between PACS and RIS 410 to reduce thesystem's regulatory footprint, for example. In certain examples, asingle database schema can be used to support functionality from a PACSthat may otherwise be missing in the integrated system 400 including RIS410 and EA 420.

Single Schema-Based RIS/PACS Integration

Certain examples provide a true combined RIS/PACS system. One schemaprovides one definition of a patient, an order, a visit, etc., that isshared by both RIS and PACS functionality. While prior approaches usedifferent RIS and PACS schema, certain examples provide one schema touse with a patient for both PACS and RIS data. Certain examples use asame schema and same middle tier for both RIS and PACS applications.Certain examples leverage the single schema for any combination ofRIS/PACS, RIS, PACS, worklist, etc., as various configurations of thesame code.

In certain examples, as separate systems are collapsed into a singlesystem, performance can be improved in certain areas. For example, datacan be modeled after caching. Information normally pulled at runtimefrom different sources can be pulled up from into a digest that isavailable when needed.

As discussed above and disclosed and described further below, one ormore of the HIS, RIS, PACS, and/or other clinical system can beintegrated for single schema operation over multiple back-ends. Incertain examples, each system includes two types of objects, aspersisted in a database. One type of object is “Objects of Domain”, suchpatient, exam, visit, etc., which are modeled after one or more realworld entities and, though an implementation/model may vary from systemto system, the information at a certain abstraction level does not varywith objects of domain. Such objects can be re-modeled using updatableviews or other such mechanisms. Other objects are “Objects of Design”that are specific to the functioning of an application. These objectsvary from application to application.

Certain examples provide an abstracted data model of a healthcare domainthat works on a variety of healthcare information system platforms.Applications can be developed on top of this model, allowing deploymentof the application with customers running a variety of systems.

Rather than replicating data from one system to another, developers canuse a consistent data model on top of which to build applicationswithout regard to underlying base system(s) used. Updates/upgrades canthereby be facilitated without downtime and with negligible servicecost.

Using existing base tables (e.g., domain tables, etc.) messysynchronization, ETL, data duplication, etc., can be avoided. A databaseagnostic approach can be provided on multiple platforms while allowingusers to retain their current data, for example. Using a single schemathat holds information of both the RIS and the PACS, for both and singlemiddle tier, a back end infrastructure can be fused together. Even whilethe back end infrastructure may be fused together, a client side canretain two applications (e.g., one for exam ordering and one for examviewing), although a single, combined application can be providedinstead. In certain examples, a combination results in a customer payingonly one license fee.

In certain examples, the integrated, single schema system includes ascalable image service manager (ISM) that can integrate with a pluralityof applications to accommodate scaling of such applications toaccommodate and work with a variety of other applications. An imagingconnection manager (ICM) provides a level of abstraction betweencomponents such that components can plug-and-play by communicating withthe ICM, which identifies and understands the component and, in turn,communicates with the ISM, which remains stable throughout. Thus, forexample, the ICM can retrieve a study from the ISM based on a studyidentifier (ID). At the ISM, such interaction to identify a study, fetchthe study, and provide the study to a viewer can be coded according to astandard application programming interface (API). On the ICM side, theICM communicates with the ISM and then provides asystem-/application-specific connection on the other side (e.g., an EAconnector, a PACS connector, etc.) to enable access.

Certain examples provide a front end user interface system with anintegrated front end but not necessarily a unified back end (e.g.,disparate systems operating according to a single schema). Certainexamples help to facilitate image lifecycle management via the singleschema-based system in conjunction with an enterprise archive (EA),DICOM source, modality, etc.

FIG. 5 illustrates an example integrated clinical information system500. The example integrated system 500 includes a workflow manager 510and an imaging services manager 520 with a plurality of overlappingfunctionality 531-534. The workflow manager 510 includes services suchas order management 511, worklist 512, reporting 513, messaging (e.g.,HL7) services 514, etc. Using an SOA 515, the workflow manager 510provides BPM 516 and communicates with shared functionality 531-534 viaan ESB 517. Via the ESB 517, the workflow manager 510 can shared a studyfile/SHP 531, exception management/matching/profiling/etc. 532,collaboration/MDT 533, prefetching 534, etc., with the imaging servicesmanager 520. The imaging services manager 520 supports servicesincluding XDS 521, MPPS 522, DICOM services 523, etc.

As shown in the example of FIG. 5, a user can access the workflowmanager 510 and/or imaging services manager 520 via one or more of aradiology reading and reporting viewer 551 (e.g., a GE Centricity® eRadCockpit provided by General Electric Company), a universal/zerofootprint viewer 552, a modality viewer (e.g., GE Advantage Workstation(AWS), GE IDI Mammography Workstation, etc.) 553, third partyapplication 554, etc. The devices 551-553 can communicate using anapplication programming interface (API) such as an image viewer API(IVAPI), etc. Orders, worklist, reports, etc., can be accessed via theworkflow manager 510 while images can be accessed from the imagingservices manager 520. In some examples, an image streaming engine 540facilitates image location and retrieval from the imaging servicesmanager 520.

For example, a user (e.g., a radiologist) can access his or herradiology review cockpit 551 and launch the universal viewer 552 fromthe cockpit 551. The universal viewer can communicate with one or moremodality image viewers such as AWS, IDI, etc., 553. Using the universalviewer 552, the user can request an image study from the imagingservices 520 via the image streaming engine 540. The imaging services520 works with the workflow manager 510 via the shared functionality531-534 to retrieve and display the requested image study for the uservia the viewer 552. Via the cockpit 551, the user can also retrieve aworklist, associated orders, etc., and generate a report after readingthe study images via the workflow manager 510. Reports and/or associatedorders can be retrieved and/or stored at one or more RIS databases 580,581 according to a single, common schema 570.

Additionally, the workflow manager 510 can interact with one or moreinformation systems 560, such as an electronic medical record (EMR),electronic health record (EHR), hospital information system (HIS), RIS,etc. The imaging services manager 520 can similarly communicate with oneor more systems including a PACS, EA, and/or VNA 561, an imagingmodality (e.g., x-ray, computed tomography (CT), mammography, magneticresonance imaging (MRI), ultrasound, position emission tomography (PET)scanner, etc.) 562, data storage (e.g., network-attached storage (NAS),direct-attached storage (DAS), etc.) 563, etc.

Thus, in certain examples, the integrated system 500 serves as a fullyfunctional RIS with a built-in image viewer. In such examples, while theexample system 500 does not perform image acquisition and archiving, thesystem 500 communicates with an EA and/or other image storage forarchiving, acquisition, etc. The imaging services manager 520 providessmart hanging protocols, user privileges, resources, etc., along withimages for the universal viewer 552 to function.

In certain examples, an imaging connection manager (ICM) is providedbetween the imaging services manager 520 and the one or more imagingback-ends 561-563. ICM connector modules are written for variousback-end systems including EA, PCAS, DICOM, XDSi, third party imagingbackends, etc., so that intricacies of such connections are abstractedfrom the rest of the system 500.

In certain examples, image metadata and location can be directlyextracted from an EA and/or other image store database. The streamingengine 540 can pull images off of the EA cache for display. In certainexamples, the system 500 queries/polls the EA and/or other archive forarrival of new studies or changes to existing studies. HL7 messages canbe sent back to the EA/other image store for patient demographic update,for example.

In certain examples, native prefetching can be provided to populate animage cache for first image display (e.g., in less than two seconds). Inother examples, a temporary file space can be provided with the system500 to provide transient storage such that images are stored astemporary files for a fraction of the time it would otherwise take toreceive them from a remote DICOM service and pass them to the universalviewer. In certain examples, a digest or pre-digest is provided togather or prefetch certain image attributes to determine a first imageto be displayed in the system 500 database. A single, expanded schemacan be used to keep information (e.g., image attributes andrelationships) to speed up first image display time and dynamicallyquery at every request for view, for example.

In certain examples, the single schema encompasses representations fromboth EA and RIS as well as supporting functionality/data provided by atraditional PACS. Rather than separate RIS and PACS schema that havedifferent formats and are stored and interpreted in different ways, oneschema provides one definition of a patient, an order, a visit, etc.,that is shared by RIS, PACS, and/or other clinical system. A commonschema allows multiple systems to look at a patient according to theirvarious data sets (e.g., PACS data, RIS data, etc.) using the sameinterpretation (and, for example, with the same middle tier forformatting, analysis, etc.). The variety of data for that patient canthen be broken down and analyzed from a RIS perspective, a PACSperspective, an integrated RIS/PACS perspective, a worklist perspective,and/or other configuration of the same code, for example. Using thesingle schema, a pre-digest of information that would otherwise bepulled at runtime from different sources can be gathered and interpretedup front so that it is available when needed or desired. Using a singleschema, functionality can communicate without using a broker as atranslator or intermediary, for example.

The schema supports both objects of domain and objects of design. Domainobjects can be reconciled into common, updatable views based on tables(e.g., tables based on domain entities such as patient, visit, exam,master file data, etc.). Design objects can often be eliminated from theintegrated system due to equivalently functionality already existing inthe system. However, design objects without an equivalent can be addedwithout conflict. Tables can be created for non-domain objects andtransactional data such as audit, implementation of rules, userpreferences, etc. In certain examples, the common schema is based on aRIS schema extended for integrated system features. As such, some RISdesign objects may be excluded. Using the common integrated schema,application developers get a consistent, database agnostic, data modelon top of which to build applications regardless of an underlying RIS(e.g., in the case of a “bolt-on” embodiment to an existing RIS, etc.),for example.

FIG. 6 depicts an architecture diagram for an example integratedclinical system 600 (e.g., similar to the system 500 of FIG. 5). Theexample system 600 is organized according to three tiers/levels/layers:platform 610, SOA and BPM 620, and application development framework(ADF) 640.

The platform 610 includes a single, unified schema 611 used to define,organize and store information (e.g., whether traditionally “RIS data”,“PACS data”, etc.). The platform 610 also includes an event and auditlog 612, access protocol (e.g., lightweight directory access protocol(LDAP), single sign-on (SSO), etc.) 613, communications security (e.g.,Internet Protocol Security (IPSec), secure sockets layer (SSL), InternetProtocol version 4 or version 6 (IPV4/6, etc.) 614, Internet Protocol(IP) and/or other networking services (e.g., domain name service (DNS),dynamic host control protocol (DHCP), network address translation (NAT),etc.) 615, etc. The elements of the platform 610 provide a base for thearchitecture 620 and applications 630 that sit on top of the platform610 to form the example integrated clinical system 600.

The service-oriented architecture and business process management 620 ofthe example system 600 include a plurality of services to driveapplications and access, for example. For example, the SOA/BPM 620provides smart hanging protocol and study fileloading/display/arrangement services 621 to arrange and display one ormore images in a study (along with associated tools, settings, etc.).Additionally, analytics services 622, smart worklist services 623,result distribution services 624, collaboration services 625, order andworkflow management services 626, etc., are provided to facilitateprocessing of an image and associated data, management of exams in aworklist to be read, distributing of reports and/or other results,collaboration and/or other consultation for review, generating oforders, etc. Further, content and functionality can be regulated throughsecurity and access control services 627. Hierarchy and relationshipscan be governed through multi-tenancy and multi-organization services634. Licensing constraints and rights can also be managed 633. Image(s)and/or other data can be pre-fetched 632.

Profiling and study edit services 631 can also be provided to a user.For example, a VNA 663 can interact with the XDS/DICOM 630 andprofile/study edit services 631 when receiving image data from a source664 such as from a PACS, directly from an imaging modality, etc. Incertain examples, an image cache can be provided in the integratedsystem 600 to communicate with a third party VNA 663 and/or PACS, aswell as XDS/DICOM 630, profile/study edit services 631, and prefetch 632for image retrieval and temporary storage. In certain examples, a VNA663 serves as the image cache.

Communications and image/information sharing can be facilitated throughHL7 messaging services 628, PIX source and consumer services 629, XDSand DICOM services 630, etc. For example, HL7 messaging 728 can be usedto transmit data with an external information system 662, such as anEMR, EHR, HIS, RIS, etc.

Using the ADF 640, one or more applications such as a smart worklist648, image display 649 (e.g., two-dimensional (2D) and/orthree-dimensional (3D), etc.), desktop integration API 650, etc., can beprovided. In certain examples, external modality systems 660 (e.g., AWS,IDI, etc.) and/or applications (e.g., third-party applications, voicerecognition, etc.) 661 can interface with the desktop integration API650, for example. Applications can also include master file and/orsystem administration 641, order entry and management 642,dictation/reporting 643, patient jacket (e.g., single patient jacket)644, operations dashboard/key performance indicators (KPIs) 645,collaboration 646, quality control/study management 647, etc.

Certain examples provide a scalable system 600 to accommodate a varietyof healthcare institutions/providers and to help ensure highavailability of the system 600 to its users (e.g., always on, zerodowntime upgrade, zero data loss, automated failover, data replication(e.g., lossless replication, etc.), disaster recovery, etc.).

Cross-Enterprise Integrated System Design

In certain examples, one or more integrated systems can be providedand/or can communicate across multiple healthcare enterprises. Certainexamples provide cross-enterprise or supra-enterprise communication,collaboration, and information sharing to provide access but retainownership and/or control of data. For example, an entity's workload canbe shared across competitors while enabling that entity to retaincontrol of its customer base but still provide access to (but retaincontrol over) relevant records. In some examples, collaboration may befacilitated between different legal entities with different systems, forexample. In certain examples, a user from a local system trying toaccess data and/or functionality from a remote system can beauthenticated by the local system and authorized by the remote system.

FIGS. 7-25 illustrate a plurality of example configurations forcross-enterprise communication and collaboration with an integratedclinical system. Various designs can be configured to help satisfy oneor more metrics including serviceability (e.g., installability,upgradability, break/fix workflows, etc.), performance (e.g.,throughput, latency, high availability, scalability, etc.), security,usability, product development, and marketability, for example.

Certain examples support cross-enterprise informational constructs suchas a single global patient jacket across multiple institutions, a globalreading worklist for a radiologist, etc., as well as facilitatingreporting into a system from which an exam being read originated.Certain examples facilitate cross-enterprise interaction without acommon master file across participating enterprises (but with, forexample, a master patient index (MPI)) and without data duplication(e.g., a single system of record).

In certain examples, a cross-enterprise arrangement is decentralized toallow participants to allow and/or restrict people, requests, etc.,according to one or more “local” rules, procedures, preferences, etc. Auser's local system can be responsible for authentication (is this userwho he claims to be?), while a target local and/or remote system may beresponsible for authorization (does this user have an ability to doX-Y-Z in my system?). In this way, existing enterprise organizations canbe leveraged into a cross-enterprise framework without further change.

For example, a trusted enterprise can reach out to a local machine, andits agent can verify that a user from the trusted enterprise has access.For example, this user is from enterprise A, and this user wants toaccess certain images from a machine in enterprise C. Enterprise Aauthenticates the user, and enterprise C authorizes the access (accesscontrol is in the hands of enterprise C). Thus, certain examplesfacilitate authentication of a user at the remote “home” system for theuser, but authorize access for the user locally at the system inquestion. By allowing each user's system to handle authentication andeach data/application's system to handle authorization for access to itsapplication/data, certain examples allow for multi-technology users(e.g., different and competing technology stacks can be used together)and cross-application communication.

Further, certain examples facilitate easy transitions for enterprisescoming into or going out of cross-enterprise sharing. For example, auser in enterprise A does not need to know anything about users inenterprise C. Enterprise A can set its own rules about users and canrevoke and/or change rules, users, etc., at any time withoutinterference from another enterprise. If enterprise C leaves thecollaboration, then enterprise C can shut down the external trustpreviously given to enterprise A and other collaborating enterprises sothat enterprise C then treats those enterprises as if it does not knowthem.

Certain examples help reduce implementation time and complexity (e.g.,an implementation time of zero) by leveraging existing infrastructureand/or capability (e.g., LDAP authentication mechanism already built into local enterprise) versus a centralized authentication/authorizationapproach (which requires enterprises to maintain their list of usersboth locally and with respect to the central server). With a centralizedapproach, if a user is disabled locally but not centrally, that userstill has access as far as the central authority is concerned; withdecentralized collaboration, the user has to ask the local enterprise.

In certain examples, radiology tasks can be organized in a single,intelligent workflow to collaboratively deliver more efficient patientcare and improved utilization of imaging resources. Certain examplesfacilitate automatic prioritization of studies across an enterprisebased on a radiologist worklist, based on the skill, sub-specialty,experience and service level agreements, and so on. Certain exampleshelp to enhance virtual collaboration between radiologists, referringphysicians, and other specialists to improve confidence in diagnosticfindings. Certain examples enable distributed radiologists to sharereading workload for studies performed at other locations. Certainexamples provide a workflow-enabled, comprehensive solution to imagemanagement, reporting, and analytics to help drive patient care. Certainexamples provide native tag morphing to optimize or otherwise improveimage sharing and workflows via a diagnostic viewer. Certain examplesfacilitate enterprise and community wide collaboration (e.g., via acloud-based and/or other server-based infrastructure, etc.).

FIG. 7 illustrates an example (simplified) cross-enterpriseauthentication and authorization configuration 700. As depicted in theexample of FIG. 7, user accounts are created in each enterprise thatallows a radiologist to view a cross-enterprise patient jacket.Passwords are kept in synch using an external mechanism. A database(e.g., Oracle® database) link is used to connect an enterprise to one ormore remote databases. Only barebones authorization is provided (e.g.,none or all) in the example configuration of FIG. 7.

FIG. 8 illustrates an example sharing of a global worklist and patientjacket based on the cross-enterprise design 700 of FIG. 7. Asdemonstrated in the example configuration 800, database (e.g., SQL)query results from local and remote sources are aggregated to bepresented as a single patient jacket. Application development(ADF)/business component (BC) is tied to a stored procedure that returnsthe patient jacket when called. The single patient jacket uses temporarytables, procedural language/structured query language (PL/SQL) tables,etc., and handles exceptions internally. Master file data (MFD)indicating exam source can be provided for remote exams, which eachinclude a reference to its local enterprise. As shown in FIG. 8,enterprise A selects columns from its patient data tables and selectscolumns at enterprises B, C, D, and E that relate to the patient as wellfor inclusion into a single patient jacket.

FIG. 9 illustrates an example opening of a study residing on enterpriseB via a viewer in enterprise D based on the cross-enterprise design 700of FIG. 7. A user in enterprise B opens a study (e.g., via a universalviewer launched from a radiology workspace/cockpit) based on a studyidentifier (e.g., a unique identifier (UID), enterprise code for thestudy, etc.). The study is found at remote system B. Thus, the universalviewer of enterprise D sends a request for the study file and associatedimage(s) to a local ISM at enterprise B. The local enterprise Dauthenticates the requesting user, and the remote enterprise B verifiesauthorization of the requesting user at enterprise D to access theidentified study at enterprise B. The remote enterprise B locates andstreams the exam using, for example, an image streaming engine, andtransfers the study file and image(s) for display via the viewer atenterprise D. The study file can be added to a worklist of therequesting user at enterprise D, for example. The worklist can indicatethat the exam is a cross-enterprise exam (and being provided remotely),for example. Display characteristics and order information from remotesystem B can be used for display of the image(s), and display settingssuch as grayscale softcopy presentation state (GSPS) information for theimage(s) can be saved at the remote system B, for example.

FIG. 10 provides an alternate view of an example cross-enterprise openstudy sequence 1000 between a local enterprise A and a remote enterprisestoring the image study. As shown in the example of FIG. 10, a user at aradiology reading workstation 1010 displays a global worklist 1012 andselects a study from the global worklist 1012 based on enterpriseidentifier and exam identifier, for example. A universal viewer 1014retrieves the requested study file from an ISM 1016, which determines,at 1018, whether the requested exam is local to enterprise A or not. Ifthe exam is local, then the ISM 1016 gets the study data from a database1020. If the exam is not local, then the ISM 1016 utilizes across-enterprise network 1022 to get the study file from an ISM 1024 atthe remote enterprise holding the data. The remote ISM 1024 gets thestudy file data from a database 1026 at the remote enterprise, forexample.

Alternatively or in addition, the viewer 1014 can get image data fromone or more image streaming engines 1028, 1032. A first image streamingengine 1028 is located at the remote enterprise, with access to retrievethe requested image data from an EA 1030. A second image streamingengine 1032 is located at local enterprise A, with access to retrievethe image data from an EA 1034.

FIG. 11 provides an example configuration 1100 for remote reading of aremote exam based on the cross-enterprise design 700 of FIG. 7. Forexample, a user seeks to dictate a report of an exam stored remotely atsystem C based on voice recognition (VR). The use opens a remote report(at system C) via a local system (system A). In response, the exam islocked at remote system C. While a local VR system is used at system A,a report generated is stored at the remote system C. An order does notexist in the local system A but, rather, is found in remote system C. Noremote order artifacts are created in the local system A.

In certain examples, a directory service, such as Microsoft™ ActiveDirectory, for user authentication and authorization can be added tocross-enterprise configurations to provide better control by individualenterprises over their data and its access. The directory service or SSOaccess control can be used to authenticate between enterprises withoutpassword exchange, resulting in better security. Web services, whichenable multi-threaded processing at lower latency than direct SQL, canbe used instead of direct SQL, for example, to create a readingworklist, patient jacket, etc. Remote web services can be used to getdata instead of directly opening remote portlets within an ADF. Data canbe collected from remote systems by a local system and presented fromthe local system. Cache optimizations can improve data retrieval, lowerlatency, and reduce network interruptions, for example.

FIG. 12 depicts an example cross-enterprise configuration 1200 usingactive directory services for authentication and authorization. Theconfiguration 1200 of FIG. 12 provides totally decentralizedauthentication and authorization. SSO can be used with directoryservices to provide tightly integrated authentication and authorization.Radiology domains within each enterprise forest can provide accessthrough two-way external trust, for example. Each participatingenterprise A-E chooses to which cross-enterprise user access is granted,as well as an associated level of access. Participating enterprisesretain full access control to their own systems. Directory services canauthenticate and authorize referrals as well without user management.Users can be provisioned and managed by information technology (IT)staff at an enterprise rather than radiology admin, for example.

FIG. 13 illustrates an example cross-enterprise configuration 1300 forauthentication and authorization using active directory services basedon the cross-enterprise design 1200 of FIG. 12. As shown in FIG. 13,remote user accounts are given local group privileges to allow access tolocal data at remote enterprises in the cross-enterprise configure 1300.Local group privileges can be used to provide SSO-enabled access toresources such as Web services, ISM, image streaming engine, zerofootprint viewer, etc. As shown in FIG. 13, a radiologist at enterpriseA may be remotely authenticated at enterprise B and then authorizedlocally at enterprise A. Some enterprises, such as enterprise E, may notprovide authorization to remote enterprise A.

FIG. 14 illustrates an example cross-enterprise configuration 1400 for asingle patient jacket based on the network design 1200 of FIG. 12. Usingthe configuration 1400, web service queries can be aggregated from localand remote sources to be presented as a single patient jacket. Remotemaster file data (MFD) can be provide for remote exams. Each examincludes a reference to its enterprise (e.g., A, B, C, D, E).

In certain examples, an exam object includes information such as patientname, patient identifier(s), visit identifier, date(s), etc. These aretransactional elements largely unique to the exam. In addition, MFD isattached to the exam such as in which facility and department the examwas performed, a name of a procedure performed (CT CHEST), attendingphysician, dictating physician, etc.

MFD represents a minimum set of data that defines a healthcareenterprise including its enterprise structure such as names offacilities, departments, locations, etc., found in the enterprise; namesof procedures performed; and users and their groups, for example.However, remote MFD is not applicable to the local site. Yet, in certainexamples, a remote exam includes MFD information as part of itsdefinition. In certain examples, MFD can be duplicated in a localsystem. Alternatively or in addition, reporting on a report exam in theremote system eliminates a need to duplicate MFD in the local system.Instead, the application bypasses the local system and fetches data fromand updates the remote system directly, for example.

FIG. 15 depicts an example cross-enterprise system configuration 1500providing a global reading worklist using a radiology reading cockpitbased on the cross-enterprise design 1200 of FIG. 12. The exampleconfiguration 1500 can be implemented similar to the patient jacketconfiguration 1400. In the example of FIG. 15, a user's radiologyreading cockpit in enterprise A creates a global reading worklist ofunread exams. By querying participating enterprises B, C, D, and E, aset of unread exams can be gathered cross-enterprise into a single listfor user review and further action.

In certain examples, additional privileges and/or filters can beintroduced (confidential patient, anonymization, etc.) in a servicelayer. Privileges can be rule-based (e.g., time of day, modality type,specialty, etc.), for example, and can be tied into the unread examslist that is returned to the requesting user. Filters can be controlledby the particular enterprise that owns the order for the global readinglist, for example. In certain examples, a radiology workstation can pulldata from remote systems for remote exams using Web services for displayvia the local radiology workstation.

FIG. 16 shows an example cross-enterprise configuration 1600 to open astudy file for radiology review based on the design 1200 of FIG. 12. Asdepicted in the example of FIG. 16, a radiology reading applicationlaunches a viewer based on an enterprise code of a desired study forreview. A local ISM (at enterprise D) accesses the study file from aremote ISM (at enterprise B) on behalf of local viewer (at enterpriseD). A remote streaming engine at the remote enterprise (enterprise B)can be used to transfer image(s) in the requested study to the reader atenterprise D. The study can be listed in the requesting user's worklist(potentially with an indicator indicating the study is across-enterprise referenced exam). GSPS and/or other display informationcan be saved in the remote system (enterprise B), for example.

FIG. 17 provides an example cross-enterprise open study sequence 1700based on the cross-enterprise design 1200 of FIG. 12. As shown in theexample of FIG. 17, an application development framework of theradiologist cockpit 1702 requests display of a global worklist 1704. Theglobal worklist 1704 includes a plurality of studies for review. Aparticular study can be selected from the worklist 1704 to be openedbased on an enterprise identifier and exam identifier. The studyidentification is sent to a viewer 1706, which retrieves the study filevia an ISM 1708 at local enterprise A. The ISM 1708 determines whetheran exam associated with the study file is local or remote. If the examis local, then the study file data is retrieved from a local database1712. If the exam is not local, then the ISM 1708 communicates via across-enterprise network 1714 with a remote ISM 1716 at a remoteenterprise. The remote ISM 1716 can get the study file data from adatabase 1718. Alternatively or in addition, the viewer 1706 can getimage data from a local image streaming engine 1724 and/or from a remoteimage streaming engine 1720. The streaming engine 1720, 1724 retrievesthe image data from an associated EA 1722, 1726.

FIG. 18 illustrates an example cross-enterprise system configuration1800 to support remote radiology reading for a remote exam based on thecross-enterprise design 1200 of FIG. 12. A local user in enterprise Awishes to dictate (e.g., via voice recognition) an output of reading anexam stored in a remote enterprise (enterprise C). The requested exam islocked at the remote system C. A local VR system is used, but aresulting radiology reading report is generated and stored in the remotesystem. The order does not exist in the local system, and no remoteorder artifacts are created in the local system.

In certain examples, an alternative design uses a central “orchestrator”including automated configuration of a grid of cross-enterprise entitiesaccording to a cross-enterprise fabric manager (XFM). Worklist/jacketdata can be cached using a coherence-based cross-enterprise cachingappliance (XCA) in addition to an imaging cache appliance (ICA) forpre-fetch. An imaging traffic director (ITD) can be used to route to afastest path to images (e.g., remote system, backup data center, XCA,etc. Certain examples provide high availability, scalability, faulttolerance, application service provider model, remote archive, enhancedserviceability, etc. As shown in FIG. 19, an example cross-enterprisegrid configuration 1900 retains a de-centralized, locallyaccess-controlled data environment but adds a “federal” oversight and/orcontrol. The example grid configuration 1900 provides federal controlvia an XFM, ITD, XCA, and ICA at a centralized node 1910, while eachindividual enterprise node A-E retains its own XCA, ICA, and activedirectory services.

In certain examples, cross-enterprise data use and data access can beseparated by a “shim” layer designed to help ensure compatibilitybetween systems, applications, etc. For example, a shim can beimplemented as a library that transparently intercepts an API andchanges parameters passed, handles operations, and/or redirectsoperations to help ensure compatibility between different systems,platforms, versions, etc.

FIG. 20 illustrates an example cross-enterprise data flow diagram 2000showing examples of local data access versions cross-enterprise dataaccess. Using local data 2010, a data model 2012 and data access 2014are known and can be governed by a local enterprise controlling the data2016. However, when using cross-enterprise data 2020 (e.g., retrievingdata from a remote enterprise to be used at a local enterprise), a modelof data 2022 is provided from a requesting system (e.g., exam datatagged with an enterprise code) and received by a cross-enterprise dataaccess shim 2024. The shim layer 2024 receives the code and redirectsand/or performs an appropriate action to retrieve, store, and/or operateon the data at the correct enterprise. As shown in the example of FIG.20, the cross-enterprise data access shim 2024 sits above a plurality ofparticipating enterprises A-C providing data access 2030-2032. The shim2024 determines an appropriate enterprise for data access 2030-2032 tothe desired data 2040-2042.

Single Patient Jacket

Certain examples leverage a cross-enterprise, integrated implementationto provide a single patient jacket, which facilitates a single view ofpatient data across multiple imaging back ends and/or multipleenterprises. The single patient jacket enables a user participating inthe cross-enterprise exchange to have a broad view of the patientthrough a single interface/application via the single patient jacket andintegrated clinical system (e.g., rather than disconnected informationand limited patient data).

FIG. 21 shows an example of vendor neutral viewing (VNV) via adecentralized model with a local data access deployment model 2100. Inthe example system 2100, data can be organized into a single patientjacket cross-enterprise through the use of cross-enterprise fabricservices (XFS) 2110-2114 associated with each participating enterprise.As shown in the example of FIG. 21, each XFS 2110-2114 interfaces one ormore local systems (e.g., RIS, PACS, EA, etc.) such that each enterprisecan connect and interact with other participating enterprises to gatherdata for a patient and combine that data in presentation to a user in asingle, global patient jacket/file/report.

FIG. 22 illustrates an example vendor neutral viewer 2200 of globalpriors for a patient. The example system 2200 includes a local VNV 2202including a priors service 2206 and cross-enterprise fabric services(XFS) 2204. The priors service 2206 uses the XFS 2204 to get priors fromone or more remote systems based on a cross-enterprise ID and an examID, for example. Thus, a user can select an exam from a worklist 2208 topull up the exam 2212 in a viewer 2210. The viewer 2210 contacts thelocal priors service 2206 to get priors for display, including local andremote priors, where applicable.

Local priors are retrieved via the priors service 2206 from a local PACS2214, which can include an image management system (IMS) 2216 and shortterm storage 2218 (STS), for example. The IMS 2216 can include adatabase storing persistent data for exams, images, etc., stored in thePACS 2214. The STS 2218 can be used to store images temporarily in afast disk-based cache (as opposed to long term on a tape library), forexample.

Remote priors are requested using the XFS 2204, which communicates withone or more participating remote VNVs 2220, 2228, 2236, 2244. Eachremote VNV 2220, 2228, 2236, 2244 includes its own XFS 2222, 2230, 2238,2246, priors service 2224, 2232, 2240, 2248 and associated storage(e.g., EA 2226, IMS 2234, PACS 2242, DICOM 2250) from which to identifyand, if applicable, retrieve priors (e.g., based on availability,authentication, authorization, etc.). As depicted in the example of FIG.22, the XFS 2222 receives a request to get priors (and, alternatively orin addition, getting an associated study file, getting a historicalreporting, getting exam notes, etc.) as well as authentication andauthorization of the requesting user/enterprise. Retrieved priors arethen sent back to the requesting XFS 2204 and/or access to the remotepriors is provided for display via the viewer 2210.

FIG. 23 illustrates an example vendor neutral viewer 2300 of a studyfile. The example system 2300 can be the same and/or similar to theexample system 2200, for example, but illustrated using a study filerather than image, for example. The example system 2300 includes a localVNV 2302 including a study file service 2306 and cross-enterprise fabricservices 2304. The study file service 2306 uses the XFS 2304 to get therequested study file contents from one or more remote systems based on across-enterprise ID and an exam ID, for example. Thus, a user can selectan exam from a worklist 2308 to pull up the exam 2312 in a viewer 2310as part of the global priors display.

The viewer 2310 contacts the local study file service 2306 to get studyfile content for display, including local and remote study file content,where applicable. Local study file content is retrieved via the priorsservice 2306 from a local PACS 2314, which can include an imagemanagement system (IMS) 2316 and short term storage 2318 (STS), forexample.

Remote priors are requested using the XFS 2304, which communicates withone or more participating remote VNVs 2320, 2328, 2336, 2344. Eachremote VNV 2320, 2328, 2336, 2344 includes its own XFS 2322, 2330, 2338,2346, study file service 2324, 2332, 2340, 2348 and associated storage(e.g., EA 2326, IMS 2334, PACS 2342, DICOM 2350) from which to identifyand, if applicable, retrieve study file information (e.g., based onavailability, authentication, authorization, etc.). As depicted in theexample of FIG. 23, the XFS 2322 receives a request for study metadata,for which it contacts its study file service 2324 to retrieve studyinformation from the EA 2326. Retrieved study information is then sentback to the requesting XFS 2304 and/or access to the remote study datais provided for display via the viewer 2310 as part of the global studyfile.

FIG. 24 illustrates an example vendor neutral viewer 2400 of imageaccess. The example system 2400 can be the same and/or similar to theexample system 2200 and/or 2300, for example, but illustrated using arequest for image access rather than image, for example. The examplesystem 2400 includes a local VNV 2402 including an image streamingengine 2406 and a streaming engine proxy 2404. A user can select an examfrom a worklist 2408 to pull up the exam 2412 in a viewer 2410 as partof an image display.

The viewer 2410 contacts the local image streaming engine 2406 to getlocal image content for display, which is retrieved from a local PACS2414, which can include an image management system (IMS) 2416 and shortterm storage 2418 (STS), for example.

Remote image(s) are requested by the viewer 2410 using the streamingengine proxy 2404, which communicates with one or more participatingremote VNVs 2420, 2428, 2436, 2444. Each remote VNV 2420, 2428, 2436,2444 includes its own image streaming engine 2422, 2430, 2438, 2446 andassociated storage (e.g., EA 2426, STS 2434, PACS 2442, DICOM 2450) fromwhich to identify and, if applicable, retrieve image(s) (e.g., based onavailability, authentication, authorization, etc.). As depicted in theexample of FIG. 24, the image streaming engine 2422 receives a requestfor an image, which it retrieves from the EA 2426 provides to the proxy2404 and/or otherwise enables access to the remote image via the viewer2410.

Deployment Examples

Certain examples facilitate deployment of an integrated, grossenterprise solution in one or more ways. For example, cross-enterpriseglobal reading may be delivered only to other participating integratedsystems. All participating enterprises run their workflow and imagingusing the integrated clinical information system solution.

Alternatively or in addition, one or more integrated systems can frontnon-integrated workflow and/or imaging systems such that participating,integrated enterprises can continue to run legacy systems for workflowand imaging while networking cross-enterprise using the integratedsystems. In certain examples, no MFD synch-up is required over thecross-enterprise grid to allow the various types of systems tointer-operate. No patient, order, or image data is stored permanentlyoutside of the enterprise from which it originated. Variation incapability of external RIS, PACS, and/or other system can be handled ata local enterprise level.

Thus, data duplication can be avoided between enterprises in thecross-enterprise framework, while individual enterprises retain completecontrol over security/access, patient and exam data, etc. Enterpriseshave freedom to join and leave the cross-enterprise arrangement withoutleaving behind traces of local enterprise data, for example.

Example Methods for Cross-Enterprise Reference Sharing and Resolution

While example implementations are disclosed and described above withrespect to FIGS. 1-24, one or more of the elements, processes and/ordevices illustrated in FIGS. 1-24 may be combined, divided, re-arranged,omitted, eliminated and/or implemented in any other way. Further, one ormore elements of systems and configurations disclosed and describedherein may be implemented by hardware, software, firmware and/or anycombination of hardware, software and/or firmware. Thus, for example,any of the example elements shown in FIGS. 1-24 can be implemented byone or more analog or digital circuit(s), logic circuits, programmableprocessor(s), application specific integrated circuit(s) (ASIC(s)),programmable logic device(s) (PLD(s)) and/or field programmable logicdevice(s) (FPLD(s)). When reading any of the apparatus or system claimsof this patent to cover a purely software and/or firmwareimplementation, at least one of the example components is/are herebyexpressly defined to include a tangible computer readable storage deviceor storage disk such as a memory, a digital versatile disk (DVD), acompact disk (CD), a Blu-ray disk, etc. storing the software and/orfirmware. Further still, example systems and configurations may includeone or more elements, processes and/or devices in addition to, orinstead of, those illustrated in FIGS. 1-24, and/or may include morethan one of any or all of the illustrated elements, processes anddevices.

FIG. 25 is a flow diagram representative of example computer/machinereadable instructions that may be executed to implement the examplesystems and configurations disclosed and described with respect to FIGS.1-24. In this example, the computer/machine readable instructionsinclude a program for execution by a processor such as the processor2612 shown in the example processor platform 2600 discussed below inconnection with FIG. 26. The program may be embodied in software storedon a tangible computer readable storage medium such as a CD-ROM, afloppy disk, a hard drive, a digital versatile disk (DVD), a Blu-raydisk, or a memory associated with the processor 2612, but the entireprogram and/or parts thereof could alternatively be executed by a deviceother than the processor 2612 and/or embodied in firmware or dedicatedhardware. Further, although an example program is described withreference to the flowchart illustrated in FIG. 25, many other methods ofimplementing the example systems, dashboards, etc., may alternatively beused. For example, the order of execution of the blocks may be changed,and/or some of the blocks described may be changed, eliminated, orcombined.

As mentioned above, the example process(es) of FIG. 25 may beimplemented using coded instructions (e.g., computer and/or machinereadable instructions) stored on a tangible computer readable storagemedium such as a hard disk drive, a flash memory, a read-only memory(ROM), a compact disk (CD), a digital versatile disk (DVD), a cache, arandom-access memory (RAM) and/or any other storage device or storagedisk in which information is stored for any duration (e.g., for extendedtime periods, permanently, for brief instances, for temporarilybuffering, and/or for caching of the information). As used herein, theterm tangible computer readable storage medium is expressly defined toinclude any type of computer readable storage device and/or storage diskand to exclude propagating signals and to exclude transmission media. Asused herein, “tangible computer readable storage medium” and “tangiblemachine readable storage medium” are used interchangeably. Additionallyor alternatively, the example process(es) of FIG. 25 may be implementedusing coded instructions (e.g., computer and/or machine readableinstructions) stored on a non-transitory computer and/or machinereadable medium such as a hard disk drive, a flash memory, a read-onlymemory, a compact disk, a digital versatile disk, a cache, arandom-access memory and/or any other storage device or storage disk inwhich information is stored for any duration (e.g., for extended timeperiods, permanently, for brief instances, for temporarily buffering,and/or for caching of the information). As used herein, the termnon-transitory computer readable medium is expressly defined to includeany type of computer readable storage device and/or storage disk and toexclude propagating signals and to exclude transmission media. As usedherein, when the phrase “at least” is used as the transition term in apreamble of a claim, it is open-ended in the same manner as the term“comprising” is open ended.

Although the following examples are described in conjunction with theexample systems and configurations of FIGS. 1-24, the example method2500 may be used in conjunction with other information systems. FIG. 25illustrates a flow diagram of an example method 2500 to facilitatecross-enterprise access to information and functionality while maintainseparation and control between enterprises by distinguishing betweenlocal and remote references.

At block 2510, content is requested via a clinical viewer. For example,a user at a clinical viewer can select an exam from his or her worklistto open a study file, retrieve one or more exams, schedule anappointment, read and report on an image, etc. At block 2520, one ormore appropriate target systems are identified as at least potentialsource(s) for the requested content. For example, a manager, service,proxy, and/or director associated with a local system identifies one ormore remote systems, connected through the cross-enterprise, which,instead of or in addition to the local system, include informationrelevant to the request.

At block 2530, the requesting user is authenticated at the local system.For example, using Active Directory, SSO, LDAP, etc., the local systemverifies that the requesting user is who he/she/it says it is. If therequesting user is validated, then, at block 2540, a target system(local and/or remote) identified as including relevant informationverifies that the authenticated requesting user is authorized to obtain,view, access, etc., that information at its system. Thus, a user who hasbeen authenticated is verified by a remote system to confirm that such auser (or that particular user, in fact) is authorized (e.g., haspermission) to access the information (e.g., receive it, view it,interact with it, etc.).

If the authenticated user is authorized, then, at block 2550, therequested content is identified at the target system. For example, oneor more services, proxy, etc., at a target system determine whether ornot the relevant content (e.g., data, application, other functionality,etc.) is in fact found at the target system. If so, then, at block 2560,the user at the local system accesses the requested content via thetarget system. Thus, if the requested data and/or functionality is foundat the local system, then the data is displayed and/or application isexecuted by the user at the local system. If, however, the requesteddata and/or functionality is found at a remote system, then the data isdisplayed and/or application is executed at the remote system butprovided to the user via the local viewer. Thus, rather than creatinglocal copies and/or providing content for localviewing/interaction/execution, the requested action can occur on thecontent's native system (local and/or remote), allowing the host systemto maintain control while still facilitating sharing and collaborationcross-enterprise. At block 2570, an outcome is displayed at the localsystem while any effect occurs at the target system. Thus, as describedabove, while the user sees the requested content and/or a result ofinteraction with that content at his/her/its local system, any update,modification, or effect occurs at the content's host system, which maybe the user's local system and/or a remote system that is part of thecross-enterprise configuration. At block 2535, the process can repeataccording to a number of identified target systems.

FIG. 26 is a block diagram of an example processor platform 2600 capableof executing the instructions of FIG. 25 and/or to implement the examplesystems and configurations of FIGS. 1-24. The processor platform 2600can be, for example, a server, a personal computer, a mobile device(e.g., a cell phone, a smart phone, a tablet such as an iPad™), apersonal digital assistant (PDA), an Internet appliance, a DVD player, aCD player, a digital video recorder, a Blu-ray player, a gaming console,a personal video recorder, a set top box, or any other type of computingdevice.

The processor platform 2600 of the illustrated example includes aprocessor 2612. The processor 2612 of the illustrated example ishardware. For example, the processor 2612 can be implemented by one ormore integrated circuits, logic circuits, microprocessors or controllersfrom any desired family or manufacturer.

The processor 2612 of the illustrated example includes a local memory2613 (e.g., a cache). The processor 2612 of the illustrated example isin communication with a main memory including a volatile memory 2614 anda non-volatile memory 2616 via a bus 2618. The volatile memory 2614 maybe implemented by Synchronous Dynamic Random Access Memory (SDRAM),Dynamic Random Access Memory (DRAM), RAMBUS Dynamic Random Access Memory(RDRAM) and/or any other type of random access memory device. Thenon-volatile memory 2616 may be implemented by flash memory and/or anyother desired type of memory device. Access to the main memory 2614,2616 is controlled by a memory controller.

The processor platform 2600 of the illustrated example also includes aninterface circuit 2620. The interface circuit 2620 may be implemented byany type of interface standard, such as an Ethernet interface, auniversal serial bus (USB), and/or a PCI express interface.

In the illustrated example, one or more input devices 2622 are connectedto the interface circuit 2620. The input device(s) 2622 permit(s) a userto enter data and commands into the processor 2612. The input device(s)can be implemented by, for example, an audio sensor, a microphone, acamera (still or video), a keyboard, a button, a mouse, a touchscreen, atrack-pad, a trackball, isopoint and/or a voice recognition system.

One or more output devices 2624 are also connected to the interfacecircuit 2620 of the illustrated example. The output devices 2624 can beimplemented, for example, by display devices (e.g., a light emittingdiode (LED), an organic light emitting diode (OLED), a liquid crystaldisplay, a cathode ray tube display (CRT), a touchscreen, a tactileoutput device, a printer and/or speakers). The interface circuit 2620 ofthe illustrated example, thus, typically includes a graphics drivercard, a graphics driver chip or a graphics driver processor.

The interface circuit 2620 of the illustrated example also includes acommunication device such as a transmitter, a receiver, a transceiver, amodem and/or network interface card to facilitate exchange of data withexternal machines (e.g., computing devices of any kind) via a network2626 (e.g., an Ethernet connection, a digital subscriber line (DSL), atelephone line, coaxial cable, a cellular telephone system, etc.).

The processor platform 2600 of the illustrated example also includes oneor more mass storage devices 2628 for storing software and/or data.Examples of such mass storage devices 2628 include floppy disk drives,hard drive disks, compact disk drives, Blu-ray disk drives, RAIDsystems, and digital versatile disk (DVD) drives.

The coded instructions 2632 (e.g., of FIG. 25) may be stored in the massstorage device 2628, in the volatile memory 2614, in the non-volatilememory 2616, and/or on a removable tangible computer readable storagemedium such as a CD or DVD.

While the invention has been described with reference to certainembodiments, it will be understood by those skilled in the art thatvarious changes may be made and equivalents may be substituted withoutdeparting from the scope of the invention. In addition, manymodifications may be made to adapt a particular situation or material tothe teachings of the invention without departing from its scope.Therefore, it is intended that the invention not be limited to theparticular embodiment disclosed, but that the invention will include allembodiments falling within the scope of the appended claims.

Although certain example methods, apparatus and articles of manufacturehave been disclosed herein, the scope of coverage of this patent is notlimited thereto. On the contrary, this patent covers all methods,apparatus and articles of manufacture fairly falling within the scope ofthe claims of this patent.

What is claimed is:
 1. A cross-enterprise enabled clinical information system comprising: a workflow manager to coordinate user workflows with respect to the system and associated content; and an image services manager configured to manage images and associated services for the system and associated content, wherein the workflow manager and image services manager are configured for cross-enterprise content sharing such that the system is to locally authenticate a user at the system and the system is to locally authorize a remote request for access to content at the system from a remote user that has been authenticated remotely, the system arranged to provide content in response to the remote request after the remote authentication has been received and the system has verified the remote user's authorization for access, at least one of the workflow manager and the image services manager providing content to the remote user depending upon a type of requested content.
 2. The system of claim 1, further comprising a cross-enterprise data access shim to transparently intercept the remote request for content and a least one of change and redirect the request among a plurality of systems participating in the cross-enterprise content sharing.
 3. The system of claim 1, further comprising cross-enterprise fabric services to facilitate a request for content from one or more remote systems by a local user at the clinical information system.
 4. The system of claim 1, wherein no master file data synchronization is performed with the remote request for access to content.
 5. The system of claim 1, wherein no historical patient data is to be transferred and persisted in the local system when content is provided in response to the remote request.
 6. The system of claim 1, wherein the workflow manager and the image services manager share at least one of study file and hanging protocol management, exception management, collaboration, and information prefetch.
 7. The system of claim 1, wherein the workflow manager is configure to interact with one or more of an electronic medical record, an electronic health record, a hospital information system, and a radiology information system.
 8. The system of claim 1, wherein the image services manager is configured to interact with one or more of a vendor neutral archive, a picture archiving and communication system, and an imaging modality.
 9. The system of claim 1, wherein the workflow manager and image services manager are configured to gather information regarding a patient from the system and one or more remote systems to form a single patient jacket for review by a user.
 10. The system of claim 1, wherein the workflow manager and image services manager are configured to gather information regarding user's worklist from the system and one or more remote systems to form a global reading worklist for review by the user.
 11. A tangible computer readable storage medium including instructions which, when executed, implement a cross-enterprise enabled clinical information system, the system comprising: a workflow manager to coordinate user workflows with respect to the system and associated content; and an image services manager configured to manage images and associated services for the system and associated content, wherein the workflow manager and image services manager are configured for cross-enterprise content sharing such that the system is to locally authenticate a user at the system and the system is to locally authorize a remote request for access to content at the system from a remote user that has been authenticated remotely, the system arranged to provide content in response to the remote request after the remote authentication has been received and the system has verified the remote user's authorization for access, at least one of the workflow manager and the image services manager providing content to the remote user depending upon a type of requested content.
 12. The storage medium of claim 11, further comprising a cross-enterprise data access shim to transparently intercept the remote request for content and a least one of change and redirect the request among a plurality of systems participating in the cross-enterprise content sharing.
 13. The storage medium of claim 11, further comprising cross-enterprise fabric services to facilitate a request for content from one or more remote systems by a local user at the clinical information system.
 14. The storage medium of claim 11, wherein no master file data synchronization is performed with the remote request for access to content.
 15. The storage medium of claim 11, wherein no historical patient data is to be transferred and persisted in the local system when content is provided in response to the remote request.
 16. The storage medium of claim 11, wherein the workflow manager and the image services manager share at least one of study file and hanging protocol management, exception management, collaboration, and information prefetch.
 17. The storage medium of claim 11, wherein the workflow manager is configure to interact with one or more of an electronic medical record, an electronic health record, a hospital information system, and a radiology information system.
 18. The storage medium of claim 11, wherein the image services manager is configured to interact with one or more of a vendor neutral archive, a picture archiving and communication system, and an imaging modality.
 19. The storage medium of claim 11, wherein the workflow manager and image services manager are configured to gather information regarding a patient from the system and one or more remote systems to form a single patient jacket for review by a user.
 20. The storage medium of claim 11, wherein the workflow manager and image services manager are configured to gather information regarding user's worklist from the system and one or more remote systems to form a global reading worklist for review by the user. 